The focus of this blog is on the wonders of government-run health-care everywhere but I also note the damage done to private medicine by a legal system that supports predatory litigation.

The long-established socialized medicine systems in Britain and Australia are a particularly relevant warning about where such systems end up.

Posts by John J. Ray (M.A.; Ph.D.)

Monday, January 18, 2010

If you must get ill in Britain, make sure it’s before 6pm

As GPs reap the rewards of their 2004 pay deal, patients are dying. It’s time to rethink our contemptible out-of-hours cover

Warm, fuzzy escapism is one honourable role of popular fiction, so Friday’s Coronation Street was justified in offering us a heart-warming medical vignette. A child had a fever; anxious divorced parents called their GP, who shortly turned up in their home, smiling, familiar, articulate and reassuring. At no point did anyone have to explain themselves repeatedly to NHS Direct “information handlers” on the phone, or wait four hours for an outsourced “provider” to send round a jetlagged foreign doctor they couldn’t understand. Nobody had to bundle the shaking child into the car to A&E, after scrabbling down the back of the sofa for change for the hospital car park.

Bless the warm nostalgia of it! Leave gritty realism to the newspapers, with the grimly unsurprising inquest reports about the day David Gray, a retired engineer, was killed by a tenfold overdose of diamorphine. It was administered by Dr Daniel Ubani, fresh in from Germany for his first dawn shift on the disgraceful, wasteful gravy train of British bought-in care. Now serving a nine-month suspended sentence back home, he freely admits that when he answered Mr Gray’s call he was in a state of “tremendous stress”, after only three hours’ sleep. Moreover, Ubani had never actually used diamorphine (his own clinic in Westphalia advertises “anti-ageing” and cosmetic services).

But you have to feel a bit sorry for the chap, as for all those who can’t resist golden temptations. UK primary care trusts, saddled with responsibility for “out-of-hours” services formerly provided by GPs, have been known to pay £800 per shift. One foreign doctor observed that he earns more in a couple of nights in the UK than in a whole month back home. European law means that a doctor certified in any EU country — even the newest and least familiar — must be automatically accepted as fit to practice here (the rest of the world is, at least, tested). Locum agencies need not make certain that the incoming doctor speaks English properly, or has had any sleep. Evidence has been given that the UK doctor who “inducted” and signed off Ubani wrote on his form that he was too busy to give him a proper assessment.

Mr Gray’s tragedy is an extreme, like the earlier death of a 41-year-old mother from undiagnosed septicaemia after six phone calls and two locum examinations. But the problem is far wider, and not confined to foreign doctors. Only 6 per cent of trusts hit the official target for prompt attention to urgent cases, and tales of incompetence abound. Try our own extended family: one serious injury to a teenager, bone exposed, met hours of indifferent delay and finally a trip to hospital (lucky they had a car. Plenty don’t). Another relative, with a nursing background, caught an incomprehensible foreign locum injecting her with a wholly inappropriate drug as a “painkiller”. Personally I can just offer one serious, basic misdiagnosis of a small post-op problem (English doctor this time, but clearly rubbish). The entry-level crassness of what he told me visibly shocked the real consultant when, after a terrified weekend, I got to a proper clinic.

Meanwhile, among the very elderly — such as my late mother — after 2004 it became axiomatic never to try for a doctor at weekends. You struggle on with your breathing problems or worsening pain until Monday, when you can see someone who speaks English, and knows you.

And so it goes on. Why? Because, in 2004 the Government blithely signed a new contract with family doctors — admittedly an undervalued service before. It boosted their pay by 30 per cent (with extra bunce for paperwork, such as making lists of fat patients) while crucially allowing them — by losing a small increment — to opt out of any responsibility for their patients outside surgery hours. Most GPs jumped at the chance. primary care trusts had to find cover: profit-seeking locum providers, such as Take Care Now which hired Ubani, mushroomed, undercut each other, and used the vast expansion of the EU and the ban on vetting or testing to keep things speedy and cheap, even with high shift fees. As to UK doctors who choose agency work, even their professional websites carry warnings that “lack of continuity and follow-up can be vocationally barren in the long run and could contribute to disillusionment and burn-out”. In other words, it’s a dehumanising and impersonal way to practice medicine. Which doesn’t bode well for the patients, either.

It has been a disaster, a thoughtless, formulaic governmental incompetence that ignored the daily realities of citizens’ lives (as does the still chronic shortage of NHS dentists, another contractual foul-up). Its effect has been condemned by Action Against Medical Accidents and the Care Quality Commission; even the Royal College of General Practitioners is uneasy. It has certainly put extra pressure on the 999 service and A&E departments. The Tories say they will reverse the contracts and make GPs collectively responsible for organising reliable care: heaven knows whether they can achieve this against BMA resistance.

And yes, doctor, I know that before the change you were often persecuted by stupid, selfish, unnecessary night calls. Yes, we do live in a society where some people dial 999 because their cat is annoying them, or ring the GP at 3am because their eyebrow tickles. But there were other ways to tackle those idiots, if only governments were not so terrified of offending voters and tabloids by bringing in sharp penalties or charges. Instead, by stealth and without much thought about consequences, they inflicted on us all a degraded and degrading service, and the BMA did nothing to stop it. The fact is that normal, considerate, responsible people do sometimes get ill and afraid after 5pm and at weekends. They deserve better than the cavalier, dangerous contempt they are currently offered.

Know the TRUTH about the Government Health Care Bill H.R.3200 - Key Points

Beware ObamaCare fine print

“No matter how we reform health care, we will keep this promise,” President Obama told the American Medical Association last June. “If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what.”

Obama’s pledge is hollow, mainly because most Americans do not own their health plans, unlike their auto or home insurance, which is their private property.

Some 159 million non-elderly Americans have employer-controlled group coverage, according to the Kaiser Family Foundation’s annual Employer Health Benefits survey. Employees may prefer to keep their current medical insurance, but their bosses can change that coverage the moment they become disenchanted, just as easily as companies switch from Coke to Pepsi in office vending machines. Employers also can drop coverage altogether.

“ObamaCare” would forbid insurers from basing rates on the individual health of their customers in any community. It also would force issuers to cover people who refuse to buy insurance until they get sick. These and “ObamaCare’s” other complexities would make insurance pricier. Thus, some employers would save money by paying fines after de-insuring their employees. Workers who cherish their health plans then would find themselves dumped into the government-run Health Insurance Exchange.

“Some smaller employers would be inclined to terminate their existing coverage,” said a recent memorandum by Medicare’s chief actuary, Richard Foster. He added: “The per-worker penalties assessed on non-participating employers are very low compared to prevailing health insurance costs. As a result, the penalties would not be a significant deterrent to dropping or foregoing coverage. We estimate such actions would collectively reduce the number of people with employer-sponsored health coverage by about 17 million.”

Also, ObamaCare would require employers to provide federally approved coverage “meaningful” coverage. “Obama’s definition of ‘meaningful’ coverage could eliminate the health plans that now cover as many as half of the 159 million Americans with employer-sponsored insurance, plus more than half of the roughly 18 million Americans in the individual market,” says Cato Institute analyst Michael Cannon. “This could compel close to 90 million Americans to switch to more comprehensive health plans with higher premiums, whether they value the added coverage or not.”

Meanwhile, Medicare Advantage covers some 11 million seniors. ObamaCare would siphon $118 billion from Medicare Advantage through 2019 and funnel it into a massive, new entitlement — even as Medicare wheezes toward bankruptcy in 2017.

The ObamaCare fine print elsewhere — particularly, the baffling prose on pages 114 to 118 of the Senate’s ObamaCare bill — seems to limit Health Savings Accounts to the individual market, and only for those under age 30. The 9.5 million workers who now enjoy Health Savings Account plans — and self-insured individuals over 30— apparently would lose catastrophic coverage and tumble into the governmnent insurance exchange. Can we Americans lose health coverage under ‘ObamaCare’? Yes we can!

If the bill passes, the U.S. health care system will face chronic political warfare

"I am not the first president to take up this cause [of health care reform], but I am determined to be the last one," President Barack Obama declared in September. But history will force the president to eat his smooth bravado if he signs anything resembling what's on the table right now.

Far from settling the issue once and for all, the bill will usher even fiercer confrontations--not only on health care but on constitutional matters of governance as well--that will make the current battle look like the political equivalent of a spit-ball fight.

The Senate and the House begin reconciling their versions of health care "reform" this week. But everyone--barring die-hard Obama supporters--now believes that the outcome is going to be more botched than Michael Jackson's nose. There is a growing consensus in both the right and the left that the individual mandate provision, which is almost certain to be part of the final bill, represents a kind of neo-feudalism. Liberty-lovers (like myself) hate it because it will mean that for the first time ever, Americans will be forced to buy a service as a condition of lawful residence in this country. Americans will lose control over their money without the government even having the decency to formally call for a tax increase.

Progressives are offended too--not because the mandate involves a new leap in state power, but because this power would be unevenly wielded. They would be fine with the mandate if it were accompanied with an outright ban on insurance company profits or at least a public option to drive these profits down. Absent that, all it will do, they argue not without plausibility, is deliver a captive audience to insurance companies.

Since the odds at this stage that the final bill will include their beloved public option are next to zero, the left's next big battle will involve reinstating it while Obama is still in office. The biggest impediment to their ambition--as the current health care battle has made clear--isn't going to be evil Republicans or the venal insurance industry, but America's system of checks and balances. In particular, the Senate filibuster rules.

These rules are what gave blue dog Senate Democrats the power to stand up to their party bosses and derail the public option even though Democrats control the White House, the House and have a near supermajority in the Senate. And so long as these rules exist, enacting this option will only get harder when Democrats lose their overwhelming political advantage as is likely to happen this November. Hence it is no surprise that the liberal punditocracy is demanding the annulment of the filibuster--even though, ironically enough, it was a Democratic-controlled Senate that reinstated it in 1975 after a long hiatus.

Filibuster is not a beautiful thing, but it is a long established tool for checking overweening political ambition--and it can't be abolished without a bruising political battle. To the extent that most laws involve an expansion of government power, scrapping it will inevitably empower the government against its citizens. What's more, a president--a minority of one--will be able to override Congress with a stroke of his pen. But even 49 senators won't be able to stop him from ramming his agenda through their chamber.

This will shift the balance-of-power away from Congress and toward the president, diminishing his incentive to court political opponents, further polarizing the country. If the Tea Party disgust with government expansion is approaching revolutionary fervor now, imagine what will happen if a serious attempt is made to mess with a basic internal check on government power to shove a public option down the country's throat.

But with or without the public option, both the Senate and House bills involve a de facto nationalization of health care. The government already pays for half of the health care consumed in this country through Medicare, Medicaid and the veteran's administration. Another trillion dollars-plus of health care subsidies will give the government a majority stake.

And there is no sign that it plans to be a hands-off stakeholder. The panoply of mandates and regulations that Democrats are proposing--guaranteed coverage of pre-existing conditions; money back to policy holders if insurance companies' administrative costs exceed 10% of their revenues, etc.--will put the government squarely in the driver's seat. No less than the Congressional Budget Office has concluded that "this further expansion of the federal government's role in the health insurance market [that the Senate bill entails] would make such insurance an essentially governmental program."

The upshot of all this won't be unlimited, top-notch health care for everyone, as the Democratic establishment is promising. To the contrary, with individual patients losing even nominal control of their medical dollars, the health care system will be powered less by patient needs, and more by collective social goals dictated by politicians driven by powerful lobbies adept at political marketing.

Nationalized health care systems always and everywhere face a contest between competing interests trying to capture scarce medical dollars. If, say, women with breast cancer shame political authorities into approving expensive cancer-fighting drugs, men launch their own campaign to shift medical dollars to prostate cancer treatment. Patients who lack political savvy or represent disfavored causes--obesity, smokers, homosexuality--inevitably get relegated to second class medical status. If money poses an unfair obstacle for patients in a market-based system as progressives allege, can they with a straight face claim that the political establishment doesn't pose a far bigger obstacle in a government-run system?

But it is not just patients who are pitted against each other; providers are too. Unlike in a market where competition and innovation is always expanding the medical pie, in a nationalized system providers are engaged in a zero-sum game. Every dollar that goes for reduction of infant mortality to a pediatrician is one that doesn't go to a neurologist for Parkinson's treatment.

Since there is no equitable formula to deal with all these competing claims, politicians under nationalized health care are constantly tinkering and experimenting to fashion the system after their own pet causes. Even basic questions as to whether a health care system should be more cost-effective or more accessible become subject to political whim. For instance, England's Labor government some years ago repealed the internal market reforms put in place by the previous Conservative government to bring some cost discipline to the country's government-run National Health Service--only to reinstate these reforms after costs started exploding once again.

In short, if ObamaCare passes next month, America's health care system won't be revolutionized so much as thrown into a state of permanent revolution. Hence, its opponents can either redouble their efforts to strangle this monster in its crib now--or prepare for endless political warfare later.

Background

Postings from Brisbane, Australia by John Ray (M.A.; Ph.D.) -- former member of the Australia-Soviet Friendship Society, former anarcho-capitalist and former member of the British Conservative party.

This blog gives a lot of attention to events in Australia and Britain -- places where there already exist systems similar to the one most likely to befall the USA if the Democrats get their way -- "Free" medical care supposedly available to all through government hospitals but with a competing private sector as well. The Canadian system is considered too Soviet to provide a likely model for the USA

TERMINOLOGY: Many of my posts concern the very instructive state of socialized medicine in Australia. Like the USA, Germany and India, Australia has a system of State governments which have substantial independence from the central (Federal) government and it is they who are mainly responsible for "free" health services. It may therefore be useful to some for me to note the standard abbreviations for the States concerned: QLD (Queensland), NSW (New South Wales), WA (Western Australia), VIC (Victoria), TAS (Tasmania), SA (South Australia).

For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Conservatives do NOT object to helping the poor. Government welfare legislation in aid of the poor was in fact first introduced by conservatives -- Bismarck and Disraeli in the 19th century. What conservatives want is for the help to be delivered in a sane manner. And anyone who thinks that government bureaucracies can run hospitals well is completely out of touch with reality.

One of the oldest "free" public hospital systems in the world is that in the Australian State where I live: Queensland. It dates from 1944 (Britain's NHS began in 1948). So its advanced state of decay reveals well where the slow cancer of bureaucracy ends up. It now has three "administrative" employees for every medical employee. All those clerks are really good at curing people, I guess! Frequent bulletins on the flailing but ineffectual attempts to "fix" the system will appear here -- as well as bulletins on the dreadful things it does to patients and the long waits they endure.

On all my blogs, I express my view of what is important primarily by the readings that I select for posting. I do however on occasions add personal comments in italicized form at the beginning of an article.

I am rather pleased to report that I am a lifelong conservative. Out of intellectual curiosity, I did in my youth join organizations from right across the political spectrum so I am certainly not closed-minded and am very familiar with the full spectrum of political thinking. Nonetheless, I did not have to undergo the lurch from Left to Right that so many people undergo. At age 13 I used my pocket-money to subscribe to the "Reader's Digest" -- the main conservative organ available in small town Australia of the 1950s. I have learnt much since but am pleased and amused to note that history has since confirmed most of what I thought at that early age.

I imagine that the the RD is still sending mailouts to my 1950s address!

NOTE: The archives provided by blogspot below are rather inconvenient. They break each month up into small bits. If you want to scan whole months at a time, the backup archives will suit better. See here or here